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Client Intake Form

Are you eligible for Social Security Disability benefits?

Before you take any further action on your claim for Social Security Disability, contact us at Golson, McCracken Inc. for a free consultation. We can review your situation with you in person or over the telephone to determine whether you are eligible, advise you of strategies to increase the likelihood that your claim will be approved, and help you determine how much your claim for benefits may be worth. Please fill out the following form as best you can so that our representatives can better understand your unique situation. Take the first step now by filling out the form below: [su_row] [su_column size="1/6"] [su_spacer size="10"] [/su_column] [su_column size="2/3"]

Full Name:*

Date of Birth:

Adult or Child?

Email:*

Address:*

City:*

State:*

Zip:*

Callback Number:*

Height:*

Weight:*

How did you here about us?

What prevents you from working?*

Highest Grade completed in school (any special education, repeated grades)

Can you read/write/do math? YesNo

All jobs you had in the last 25 years, and the last day you worked: (i.e. fired, retired, walked off, quit etc..)

Present income and source
Answer can be none as well, also include child support, food stamps etc.

Have you received Workers compensation, VA, short term, long term disability benefits? YesNo

Marital Status

If married: Spouse name? working? Getting Disability?

Tobacco use, Alcohol use, drug use:
(not prescribed medications, i.e.. cocaine, marijuana etc..)

Last time you saw a Doctor and why?

Are you taking prescribed medications? YesNo

Current Insurance:

Children and their ages:

Current and prior applications status/information:

Do you have someone representing you now? YesNo

Anything else you would like us to know?

The information on this website is for general information purposes only. Nothing on this site should be taken as legal advice for any individual case or situation. This information is not intended to create, and receipt or viewing does not constitute, a client relationship.